Promoting Mental Health in Adolescents: “Teens Mental+”, a Nursing Intervention Program Based in the Positive Mental Health Model

Abstract

Adolescence is a life stage characterized by significant physical and emotional changes in which the opportunity to enhance protective mental health factors is crucial. Evidence shows that psychoemotional well-being at this stage has worsened in recent years, being a time of special vulnerability for mental health problems. Positive mental health (PMH) is understood as the mental health of healthy individuals built on optimizing overall well-being through the acquisition of psychosocial competences. In this sense, it seemed timely to develop an original program to promote PMH in adolescents, since there are no structured and validated programs in this area focused on this population. This article presents a nursing intervention protocol aimed at promoting PMH in adolescents based on Lluch’s multifactorial model. The program addresses its six factors: Personal Satisfaction; Prosocial Attitude; Self-Control; Autonomy; Problem Solving and Interpersonal Relationship Skills. The PMH Program arises as a response to the need to implement the mental health promotion in adolescents through an integrated model in three sessions, which can be systematically dynamized by health providers, through standardized procedures and adjusted to the adolescent’s needs. Interventions in educational centers have proven to be the ideal setting for these interventions.

1. Introduction

Adolescence is characterized by biological, social, brain and cognition changes. It is defined as the period of development from childhood to adulthood at ages 10 to 19, which is influenced by personal development and cultural norms [1]. Evidence shows that adolescence is a particularly vulnerable period, where emotional and social development challenges have a greater impact. The transition and maturation into adulthood during this time can be especially difficult [2,3].

There is growing concern about mental health in the early stages of life not only because of its influence on general health, well-being and quality of life but also because of its impact on the achievement of a fulfilling life and the risk of experiencing mental health problems later in life [4].

Different international agencies warn of the importance of addressing mental health complications in adolescents today. Research findings confirm that adolescents have increased rates of psychological stress, insomnia, post-traumatic disorders, increased substance use, problematic technology use and symptoms of anxiety and depression, especially in the aftermath of the COVID-19 pandemic [4,5,6,7]. Given these considerations, mental health care in adolescence represents a priority for both, action and research. Indeed, the Sustainable Development Goals (SDGs) point to the need to address adolescent mental health, yet there is a lack of research and proposals on the matter. Of the 17 goals, only six have gender- and age-specific indicators. Only 18 SDG indicators explicitly call for disaggregation by gender and age. There is, therefore, little information on the lives of adolescent girls and boys, and their specific needs and vulnerabilities remain almost invisible to policies and programs. The Nursing Program Intervention presented here, “Teens Mental+”, aims to contribute to this need.

Likewise, it is important to highlight that some authors offer a new paradigm of understanding adolescence, viewing it as a stage of opportunities rather than just vulnerability, emphasizing the potential for increased learning about self-care and the adoption of health-promoting lifestyles [8]. This perspective emphasizes the potential to enhance emotional well-being, self-care learning and the adoption of lifestyles that promote health [9]. Emotional well-being can be understood from different perspectives. Most authors integrate concepts such as positive mental health (PMH), quality of life, life satisfaction, happiness, social capital and functioning, resilience, or positive psychology [10]. Specifically, the PMH model provides an ideal framework for understanding mental health and emotional well-being, aligning with the salutogenic vision proposed by Antonovsky (1974) [11,12]. According to the salutogenic model, in the process leading to a person’s health and quality of life, his or her capacity to manage life events is crucial [13]. This capacity is called sense of coherence (SOC) and can be described in three dimensions: comprehensibility, manageability, and meaningfulness. Several studies have shown a relationship between adolescents’ SOC and health in terms of quality of life, healthy behavior, mental health and family relationships [14]. A salutogenic approach in health promotion would involve discussing with students their perceptions of their particular contexts and their own skills, talents, interests, desires, aspirations, and motivations related to mental well-being. Contextually provided choices and personal assets could be considered mental health actives once students are able to recognize and use them [15].

PMH is the inherent strength that keeps individuals moving forward even in the face of adversity. If we understand mental health as an entity in itself, PMH would form a segment within it, being a product of several factors and, as can be seen in Figure 1, extending beyond the simple duality of the health-illness continuum [16]. PMH is a concept initially coined by Jahoda in 1958 to describe a framework for enhancing the mentally healthy aspects that individuals possess whether they are in a state of absence of disorder or, on the contrary, experiencing a disorder [17]. Jahoda defined spheres that make up PMH such as attitudes toward oneself, growth and self-actualization, integration, autonomy, perception of reality and mastery of the environment. Subsequently, Lluch extensively developed Jahoda’s model with the aim of constructing a scale that allows its assessment [18,19]. Other concepts such as resilience or psychological well-being developed by Ryff (2014) are closely related to the PMH’s construct [20].

PMH is present in both mental health and mental illness, supporting Keyes’ two-dimensional model of mental health according to which PMH is an independent dimension, although it is interrelated with mental illness [21]. So, this PMH’s construct provides us with a strategy for improving care based on health promotion and the prevention of mental health problems.

It should be noted that although the PMH model has been applied in adults, to the best of our knowledge, no studies have been conducted in the adolescent population. For this reason, several mental health nurses from the University of Alcalá deem it pertinent to emphasize the strengths of the model and its applicability in both research and health promotion interventions, aiming to assess feasibility and impact on emotional well-being.

To achieve this objective, the recommendations for action outlined in the “Guidelines on Mental Health Promotion and Preventive Interventions for Adolescents” published by the World Health Organization (WHO) in collaboration with the United Nations International Children’s Emergency Fund (UNICEF) were reviewed. It was assessed that interventions should be designed for the entire adolescent population and for specific groups of greater vulnerability (i.e., those affected by humanitarian emergencies, adolescents with emotional symptoms, adolescents with disruptive behaviors, etc.) [22].

There are several approaches to describe the program implemented in schools to promote mental health and well-being in adolescents, including social and emotional learning, character education, mental health literacy, mindfulness-based interventions, or strengths-based education. These emphasize social–emotional learning and the active participation of adolescents. When focusing on promotion, it is important to recognize the school environment as a natural context in which young individuals can develop their autonomy, safety and personal rights. There is significant evidence that school-based mental health promotion programs improve mental health, well-being and educational outcomes [10].

Evidence also shows that the nurse is the most appropriate professional to provide PMH education in schools, and especially school nurses, because they are the most available health professionals in the natural environment of children and adolescents to provide health education and health promotion, although it could also be carried out by other professionals trained in mental health promotion such as counsellors or psychologists [23,24]. However, the programs do not cover all component areas of PMH as other existing adult programs do [25].

For this reason, an intervention program called “Teens Mental+” was designed, taking into consideration the PMH model developed by Jahoda and Lluch. This model encompasses different factors related to the mental health construct in adolescents, particularly among secondary school students, in order to improve the existing evidence on the subject and inform mental health care planning for this population.

The program to promote PMH in adolescents consists of three brief interventions to be developed longitudinally, taking into account the different stages of adolescence (puberty, middle, and late) with a gender perspective. It is recommended that this program continue the PMH promotion interventions conducted in childhood and be followed by interventions aimed at young adults, ensuring the promotion of PMH throughout life.

Scholz and collaborators highlight that health promotion intervention programs should consist of at least 10 sessions with each session lasting no more than one hour and scheduled not too far apart. However, these same authors conclude that the effectiveness of the program greatly depends on the active participation of the students [26].

Therefore, considering the conditions of the schools and the feasibility of the intervention, it was decided that each intervention would be brief and take place over three sessions.

Motivated by the need to provide a relevant nursing response, we develop an intervention designed by mental health nurses for the promotion of PMH, since it has been addressed that this type of mental health promotion interventions in the educational setting are particularly relevant [26,27,28].

There are three principal objectives of this study:

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To promote adolescent mental health literacy: increase adolescents’ knowledge of what mental health is, the importance of mental health self-care, and what constitutes mental health.

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To promote PMH in middle adolescents aged 12–14 years in educational centers.

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To analyze the effectiveness of a PMH intervention in adolescents’ life satisfaction and psychological well-being.

2. Materials and Methods

2.1. Study Design

A quasi-experimental design study will be conducted with a waitlist control group without the random assignment of participants to conditions or waitlist.

The study will be carried out in seven secondary school centers in the area of influence of the Príncipe de Asturias Hospital in Alcalá de Henares (Madrid).

This study is part of a research project led by the University of Alcalá and the Príncipe de Asturias Hospital and has been favorably evaluated by the Research Ethics Committee of the University of Alcalá (Code: CEIP/HU/2021/2/004). Given the age of the participants, signed informed consent will be requested from the parents as well as assent from the children through the different participating educational centers.

The nurses assigned to conduct the intervention across different groups will undergo prior training in sessions outlined in the in the designed PMH intervention. These interventions will be carried out in the classrooms by two nurses together with the presence of the group’s school tutor to facilitate a trusting environment.

For the design of the intervention, the Mentis Plus Adult Public Health Promotion Program by Teixeira, Sequeira and Lluch (2021) was extensively reviewed previously [25]. A proposal was then drawn up to proceed with its evaluation and a short intervention modality (3 sessions) to be developed in the context of educational centers.

However, it is hypothesized that the intervention could improve adolescents’ attitudes toward mental health care, improve their understanding of the concept and its relationship with well-being (i.e., mental health literacy), and contribute to reducing social stigma.

2.2. Target Population

2.2.1. Inclusion Criteria

Adolescents between 12 and 14 years old are targeted, as this is a critical age for the consolidation of personality and the acquisition of social skills necessary for integration into adult life.

2.2.2. Exclusion Criteria

Students who do not have sufficient linguistic competences for written and oral comprehension to actively participate in the intervention were excluded from the study.

The sample size will consist of all students enrolled in these schools for the selected academic year (thirteen-year-old students), which will be approximately 850 adolescents. Each center has an even number of groups per grade, with students either receiving the intervention with their group or being placed on a waiting list, as the intervention is group-based.

2.3. Measures

Assessment measures will be collected at three points in time: (A1) a pre-intervention assessment at the beginning of the intervention program for both the intervention group and the control group; (A2) a post-intervention assessment 6–7 weeks after the first assessment to all groups (this second assessment will also serve as the pre-intervention assessment for the waitlist group, as it is followed by the intervention for that group); and (A3) a post-intervention assessment in the waitlist group. Sociodemographic variables will be collected only during the first assessment for all participants. Each participant will be assigned an anonymous code for identification purposes, which will be used in all assessments.

In the present study, besides sociodemographic variables, variables related to the health status and lifestyle habits of the participants will be collected and subsequently analyzed. The following measurement instruments will also be considered:

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Positive Mental Health Questionnaire by Teresa Lluch (1999) [18]. This scale has been created and validated in its Spanish version. It consists of 39 items scored on a Likert-type scale ranging from 1 (strongly disagree) to 7 (strongly agree). It has no subscales, providing only an overall score.

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Life Satisfaction Questionnaire (Huebner, 1991) [29] with its Spanish version recently validated by Galíndez and Casas, (2010) [30]. It consists of 7 items scored on a scale from 1 (strongly disagree) and 7 (strongly agree). It has no subscales, providing only an overall score. There are 3 reverse items: 2, 3 and 4.

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Riff’s Psychological Well-Being Questionnaire (1995) [31], Spanish version by Díaz et al. (2006) [32] and adapted to children and adolescents by Stavraki et al. (2021) [33]. This questionnaire includes 18 items in a total of 6 dimensions that assess self-acceptance, mastery of the environment, positive relationships with others, autonomy, personal growth and life purpose.

2.4. Data Analysis

The researcher analyzing the data will not know to which group the participants belong. A descriptive analysis of participant characteristics will be performed, using measures of central tendency and dispersion for quantitative variables and frequency distributions for qualitative variables. A 95% confidence interval will be taken into account. Exploratory analyses of the variables of interest will also be performed to study possible correlations and/or prognostic factors.

In the preliminary analysis, descriptive statistics will be calculated, and pre-intervention data (A1) will be analyzed to examine any differences between groups prior to the intervention. To evaluate the efficacy of the interventions, t-tests and/or intragroup and intergroup analysis of variance (ANOVA) will be performed for related and independent samples. Cohen’s d will be used to calculate the effect size. All analyses will be performed using SPSS statistical software (version 29).

2.5. Intervention

For the design intervention, a process of critical and contextual reasoning was carried out among mental health nurses with direct care experience with adolescents, analyzing the different factors, their linkage and relationship and the sequence that could be considered most effective for positive health outcomes.

The multifactorial PMH model developed by Lluch (1999) is based on six factors (

Table 1. Conceptual aspects that define each of the six factors contemplated in Lluch’s multifactorial PMH model [18].

Factors	Conceptual Aspects
F1—Personal Satisfaction	This refers to satisfaction with yourself (self-concept/self-esteem), with your personal life and with your prospects.
F2—Prosocial Attitude	It includes a person’s sensitivity to his or her social environment, the attitude and desire to help and/or support others, and the acceptance of others and differential social facts.
F3—Self-Control	This is the person’s ability to cope with stress and conflict, emotional stress and conflict, emotional balance/emotional control, and tolerance to anxiety and stress.
F4—Autonomy	It includes the ability to make one’s own decisions using one’s own judgement, self-regulating one’s own behavior and maintaining a good level of self-confidence/self-esteem.
F5—Problem Solving and Self-Actualization	It refers to a person’s analytical capacity, decision-making skills, as well as their flexibility/ability to adapt to change, developing an attitude of continuous personal growth and development.
F6—Interpersonal Relationship Skills	It includes a person’s ability to communicate and establish intimate interpersonal relationships and empathy/ability to understand the feelings of others. It is the ability to offer emotional support.

), which are somewhat different from the initial criteria proposed by Jahoda (1958) [17,18]. These factors are as follows in Table 1 [18].

In this sense, the 6 factors of the original PMH construct were combined in 3 work sessions. That is, linking personal satisfaction and self-control, which is understood as intrapersonal dimensions especially related to affective aspects (session 1); autonomy and problem-solving processes linked to cognition (session 2); and finally, in a more interpersonal dimension, prosocial attitude and interpersonal relationship skills (session 3) (Figure 2).

Each session will address factors whose content shares construct affinity, following a sequence from self-knowledge and integration of the self to autonomy, independence, and self-realization, mastery of the environment, and enhancement of prosocial competencies. In other words, it is a journey that progresses from intrapersonal to interpersonal skills.

The design and planning of the content of the different sessions is developed by specialist mental health nurses working with children and adolescents and delivered by nurses trained in the application of the different sessions. Figure 3 shows the organization of the considered PMH factors, their sequence and the protective determinants of mental health.

The sessions will be given in the secondary schools themselves, in small groups of no more than 20 students, utilizing the group tutoring spaces within the timetable. To carry out the sessions, the participation of two nurses is recommended, and to create a climate of trust and facilitate active participation, the students should be accompanied by one of their teachers during the sessions.

The estimated average duration of the sessions will not exceed 1.5 h to avoid fatigue. The contents and dynamics of the sessions were carefully selected in order to promote participation, insight, and metacognition while also avoiding the emergence of crises or potential risks.

Each session was accompanied by digital presentations and writing or drawing materials to facilitate the understanding of the concepts covered and encourage personal and group reflection. For a description of the aims, contents and materials developed in each session, see

Table 2. Materials and contents developed in session 1.

Session 1: Tips for Feeling OK and Control My KOs
Objectives: - Strengthen personal identity. - Identify strengths and aspects for improvement. - Become aware of the importance of a positive vision of the world: values and life project. - Recognize and manage emotions.	Contents: - Concept of mental health, identity and self-esteem. - Personal self-knowledge: strengths and aspects for improvement. - Positive values and life project. - Emotional management: recognition and regulation and self-control techniques.
Resources: - Multipurpose room. - Projector/digital whiteboard. - Audiovisual resources. - Dynamic photocopies and reinforcement material. - Writing/painting materials.	Activities: - Presentation of the session. - Brief notions about “Feeling good, taking care of our mental health, LET’S TALK ABOUT IT”. - DYNAMIC 1: My self-esteem. - Brainstorming: Positive values. - DYNAMIC 2: Imagine your future. - Brief presentation: Emotions, why do I love you? SELF CONTROL. - DYNAMIC 3: Stop! I know my red line. - Sharing and debate. - Keep calm! Guided breathing. - Doubts, synthesis and farewell. - Infographic: positive mental health decalogue.
Evaluation: - Satisfaction survey.

,

Table 3. Materials and contents developed in session 2.

Session 2: More Capable Than I Think
Objectives: - Value the importance of promoting our autonomy, self-care and decision-making capacity. - Know areas in which it is necessary to promote personal autonomy. - Prepare to make decisions and solve problems. - Increase interest in learning and achievement motivation.	Contents: - Concept of autonomy, independence and self-care. - Psychosocial needs. - Decision-making and problem-solving process. - Time organization and prioritization. - Learn to learn throughout life.
Resources: - Multipurpose room. - Projector/digital whiteboard. - Audiovisual resources. - Dynamic photocopies and reinforcement material. - Writing/painting materials.	Activities: - Presentation of the session, brief review of the previous session. - Audiovisual transition. - Definition of autonomy and its impact on independence and self-care. - DYNAMIC 1: Autonomy vs. responsibility (want/power). - What do we need to make decisions? - Audiovisual summary of autonomy and responsibility in decision making. - Relationship between emotions and thinking and impact on decision making. - Sharing and reflection on emotional regulation. - Review of the decision-making process. - DYNAMIC 2: Maximum screw-up or total success. - Keep calm! Guided breathing and safe place visualization. - Doubts, synthesis and farewell.
Evaluation: - Satisfaction survey.

and

Table 4. Materials and contents developed in session 3.

Session 3: Be Social and Ask For Help
Objectives: - Understand the concept of social skills. - Learn and apply different forms of communication (passive, aggressive and assertive). - Identify the relationship between social relationships, the way of communicating and self-esteem and self-concept. - Identify bullying, its harmful effects and establish and understand the help network.	Contents: - Concept of social skills. - Relationship between these and the learning process. - Conflict resolution. - Passive, aggressive, and assertive communication styles. - Identification and debate/brainstorming exercises. - Identification of bullying/differentiation of types of violence. - Support/help networks.
Resources: - Multipurpose room. - Projector/digital whiteboard. - Audiovisual resources. - Dynamic photocopies and reinforcement material. - Writing/painting materials.	Activities: - Presentation of the session, brief review of the previous session. - Brainstorming about the concepts that are included within social relationships. - DYNAMIC 1: RATATOUILLE video visualization and differentiation through debate of the different types of communication. - DYNAMIC 2: development of assertive communication style. - DYNAMIC 3: practical exercise of different communication styles in response to proposed situations. - Audiovisual bullying, types of violence with video and identification of help networks. - Keep calm! Guided relaxation. - Doubts, synthesis and farewell. - Infographic: help resources.
Evaluation: - Satisfaction survey.

.

The students received a weekly session with no more than 15 days passing between sessions in order to facilitate the integration of the content from one session to the next.

3. Program Evaluation

There are different questionnaires that assess both PMH [34] and mental health literacy [35,36]. Specifically, the questionnaire proposed by Lluch was originally composed of 39 items [18]. This questionnaire has been translated into different languages and used in different adult and adolescent populations [37,38,39]. In this study, the intervention was evaluated at the clinical level with different scales, including Lluch’s PMH scale.

Lastly, it is recommended to assess the satisfaction levels of adolescents and teachers both at the end and during the development of the sessions. Additionally, it is important to monitor the level of compliance with the sessions, and any participant absences should be recorded.

Finally, the material and human resources needed for the intervention will be recorded in order to have a clear budget to offer this type of intervention in other grades and centers in the future.

4. Conclusions

The salutogenic orientation presents itself as a truly viable and beneficial paradigm for adolescent mental health research, which makes research initiated in this area particularly relevant.

As highlighted by the experts, programs promoting PMH are needed to incorporate evidence into clinical practice, the development of nursing services, nursing research and the possibilities of synergies between groups. Specifically, the development of an adolescent program that integrates all dimensions of PMH is a useful tool and easily applicable in educational settings in a natural way.

Within the different interventions being carried out, Jahoda’s PMH model offers an unquestionable opportunity to understand psychological well-being, enhance areas of improvement and detect weaknesses.

Community nurses, school nurses, and mental health nurses, as active health agents, are the most appropriate professionals to carry out this program with adolescents in collaboration with educators and families. However, the intervention program could be implemented by other health and social agents with specific training.

The evidence reviewed emphasizes that interventions carried out in educational contexts have been shown to be the ideal setting for achieving positive health outcomes in this population.

The PMH program presented in this document arises in response to the need to implement the promotion of mental health in adolescents through an integrated model in sessions, which can be systematically dynamized by health agents, through standardized procedures and adjusted to the adolescent’s individual needs within their natural social contexts such as the school environment.

It is recommended to continue this program with the rest of the promotion interventions carried out in childhood and adolescence, adapted to each stage, so that they are truly internalized and ensure the acquisition of skills that can be carried out on a day-to-day life experience. Ideally, it should be followed by interventions aimed at young adults, thus ensuring the promotion of PMH throughout life, as it is understood that three isolated sessions are unlikely to have a significant impact on adolescents.